Dear Prospective Certified Nursing Assistant Student:

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1 Dear Prospective Student: We are pleased to welcome you to Alvin Community College and look forward to assisting you in starting your career goals in healthcare. As a, you will have many doors of opportunity open to you in the healthcare arena. The CNA program is part of the Department of Continuing Education Workforce Development. Therefore, any correspondence with the campus must be labeled Dept of CEWD to prevent your mail from being bogged down. A complete mailing address is below. Please complete the packet of information and then you may come by Building H, room 103 on the Alvin Community College campus. If you have questions regarding the program, please me at or call We wish you great success with the program and welcome you again! Sincerely, Diane Ives, RN Director of Program Stacy Ebert, DC Director of Health and Medical Programs Alvin Community College Dept of Continuing Education 3110 Mustang Road Alvin, Texas * MUST BE CPR CERTIFIED BEFORE START OF CLINICAL * MUST BE ABLE TO READ, WRITE AND UNDERSTAND ENGLISH * MUST HAVE YOUR PACKET SIGNED BY PROGRAM DIRECTOR PRIOR TO REGISTRATION 1

2 Student Application for Course Admission Health Care Program NAME SOC SEC# DATE ADDRESS (Street) (State) (Zip Code) PHONE ( ) ALTERNATE PHONE ( ) EMERGENCY CONTACT (Name) (Relationship) (Phone #) CURRENTLY EMPLOYED: WORK HOURS/WEEK (OUTSIDE HOME) DURING COURSE? HAVE YOUEVER BEEN CONVICTED OF A FELONY? (IF YES, PLEASE CONTACT DIRECTOR OF CNA PROGRAM.) ADDRESS (REQUIRED) I,, HEREBY STATE THAT ALL INFORMATION (Print Name) PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. (Signature) (Date) STUDENTS WITH DISABILITIES: This college adheres to all applicable federal, state, and local laws, regulations, and guidelines with respect to providing reasonable accommodations as required affording equal educational opportunity. ACC provides reasonable accommodations for qualified individuals who are students with disabilities. It is the student s responsibility to contact the Counseling Center in a timely manner to arrange for appropriate accommodations. Once the disability is identified, please notify your Instructor for additional modifications. 2

3 MEDICAL HISTORY FORM Health Care Program Student Name: Date of Birth NOTE: While confidentiality of this information will be maintained, full health information is necessary for the student s protection as well as that of others. Medical History: (To be completed by Student) Please identify any of the following for which you have received medical treatment within the past five years: Please list (with dates if possible) Rheumatic fever Menstrual disorders Joint disease Back injuries Epilepsy Cardiovascular disease Hay fever Diabetes Sinusitis Frequent colds Tuberculosis Thyroid disease Anemia Asthma Ulcer/colitis Hypertension Frequent headache Other (please describe) 1.Chronic illnesses 2.Current medications 3.Physical limitations 4.Currently pregnant* *If yes, must provide Physician s release Primary Care Provider s Name (Please Print) Office Address (Street) City State Zip Telephone I, HEREBY STATE THAT, TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS TRUE AND FACTUAL. Student Signature Date 3

4 IMMUNIZATION RECORD Health Program Student Name: Date of Birth Tuberculosis Screening. Skin test OR Chest x-ray (if skin test is positive). Must be within 12 months prior to start of course. TB Test Date: Chest x-ray date: Date Read: Results: Immunizations The Texas Dept. of Health requires the following immunizations for students enrolled in health related courses: Measles, Mumps, and Rubella (German Measles) (all students born after 1956) 1 dose measles, mumps, AND Rubella vaccine administered on or after 1 st birthday OR serologic confirmation of immunity Tetanus/Diphtheria (all students) 1 dose TD within past 10 years (mo/day/yr must be recorded) Varicella (Chicken Pox) (all students) 2 doses of Varicella vaccine on or after 1 st birthday OR immunity verified by student/parent/physician OR serologic confirmation of immunity Hepatitis B series of three immunizations OR serologic confirmation of immunity Date (mm/dd/yr) Vaccine MMR (measles, mumps, rubella) T/D (Tetanus/Diphtheria) Hepatitis B (3 doses) Varicella (Chickenpox) /Date of Disease Validation Signature/Stamp Must complete statement below I, hereby state that all information provided above is true and (Print Name) accurate to the best of my knowledge. (Signature) (Date) 4

5 DECLINATION OF HEPATITIS VACCINE Health Care Program I, have been duly notified of the (Print Full Name) hepatitis B requirements for healthcare providers, have been directed to resources for obtaining this vaccine, and choose to decline receiving this vaccine at this time. Accept this as my official statement of declination of hepatitis vaccine series. (Signature) (Date) 5

6 ALVIN COMMUNITY COLLEGE CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK (IN COMPLIANCE WITH THE FAIR CREDIT REPORTING ACT FCRA) To provide a safer, more secure workplace, criminal history background checks are now an integral part of the employment procedure. In an effort to avoid negligent hiring incidents, background checks are conducted on all candidates recommended for regular, full time positions. Alvin Community College uses First Advantage Background Services, which provides background screening services on a local and national level for this element of the employment procedure. PLEASE PRINT / TYPE DATE: DEPARTMENT: NAME: (Last) (First) (M.I.) (Maiden Name) (Other Last Name) (Other Last Name) ADDRESS: (Street) (City) *(County) *(State) *(Zip) DATE OF BIRTH: (MM/DD/YYYY)** (Social Security Number) ** M F W B H API * A s shown on the original application ** To be used only for Criminal History Searches; not a part of the Personnel File I am an applicant for employment and/or current employee with ALVIN COMMUNITY COLLEGE, and have been advised that as a part of the application / employment process, the Employer conducts a criminal history background check. By submission of this form, I consent to the Employer, use of any information provided in the application process in performing the criminal history check. The Employer has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer employment. In addition, I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of the Employer. Under the Fair Credit Reporting Act (FCRA), I have been advised that upon request, I will be provided the name, address and telephone number of the reporting agency, as well as the nature, substance and source of all information. Signature is not required; completion of the form will serve as authorization for the background check 6

7 CNA REGISTRATION CHECKLIST The following forms are required at the time of registration. There will be NO exceptions. TO BE COMPLETED BY CEWD OFFICE PERSONNEL REQUIRED DOCUMENTS RECEIVED APPLICATION PROOF OF CPR (OR ENROLLMENT THE CLASS) TB SCREENING RESULTS IMMUNIZATION RECORDS DECLINATION OF HEPITITIS BACKGROUND CHECK RECIEPT FINANCIAL AID APPROVAL (IF APPLICABLE) RECEIVED BY: DATE: 7

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